Setting: Primary care office
Chief concern: Blood pressure re-check
HPI: Douglas Brown is a 43-year-old black male with history of hyperlipidemia, obstructive sleep apnea, obesity, and recent office visits where his blood pressure was elevated. Six months ago, his blood pressure was 153/97.
A repeat blood pressure taken 3 weeks later showed his blood pressure to be 157/91. At that time, he wanted to try non-pharmacological options, so you recommended dietary changes, to be tried for 6 months.
ROS: Positive for frequent morning headaches, seasonal allergic rhinitis, heavy snoring, easily fatigued and occasional heartburn with spicy food.
Past Medical History: Obesity, Hyperlipidemia
Past Surgical History: None
Medications: Atorvastatin 10mg PO daily
Family History: His father died of a myocardial infarction at the age of 63. His mother has diabetes, hypertension, and hyperlipidemia. He has four adult siblings, all of whom have hypertension.
Social History: Mr. Brown is married, and has two healthy children, ages 4 and 7. He works as a janitor, does not own any pets, and apart from janitorial work, leads a sedentary lifestyle. He smokes five cigarettes per day, drinks alcohol during social occasions, and never more than three servings on any given night. He has never used illicit drugs.
Exam:
Test |
Value |
---|---|
T |
98.1 |
HR |
91 |
BP |
166/92 |
RR |
18 |
SpO2 |
96% |
BMI |
33 |
General: NAD, obese in habitus, minimal facial plethora
HEENT: normal nasal and throat mucosa, no JVD, eyes clear, neck circumference 18”
Chest: CTA bilaterally with good air exchange
CV: RRR with normal S1 and pronounced S2, laterally displaced PMI
Abdomen: no organomegaly or tenderness, normal bowel sounds. Central adiposity is present.
MSK: no joint swelling or deformities, normal ROM
Skin: no rashes, no excoriations
You repeat the blood pressure after having the patient sit for five minutes, with legs uncrossed, in a quiet room, with no talking. His repeat blood pressure is 158/90.
You discuss these results with Mr. Brown and recommend medication to get his blood pressure under control. He is initially resistant, but you explain some of the issues which can arise with chronically high blood pressure, and he agrees to start chlorthalidone and return after 1 week for blood work. His labs from this visit are normal.
He comes back one week later, with the following labs:
Test |
Value |
---|---|
Na |
134 |
K |
3.4 |
Cl |
96 |
HCO3 |
23 |
BUN |
16 |
Cr |
1.12 |
Ca |
10.0 |
Urinalysis
Item | Value |
---|---|
Urine Type | U Cath |
Urine Color | Straw Yellow |
Urine Appearance | Clear |
Sp Grav | 1.021 |
pH | 6 |
Leukocyte Esterase | Negative |
Urine Nitrite | Negative |
Urine Protein Dipstick | Negative |
Ur RBC | 0-4 |
Ur WBC | 0-4 |
You ask him to continue this dose, and keep a blood pressure journal. He should take the blood pressure at the same time each day, should never skip medication doses, and should continue to attempt dietary changes and weight loss to further lower his blood pressure and cardiovascular risk scores.
Three months later, you increase the dose as his blood pressure remains elevated.
Three months later, Mr. Brown presents for a checkup to your office. He says he’s ‘feeling great’.
His exam is as follows:
Test |
Value |
---|---|
T |
98.7 |
HR |
86 |
BP |
161/94 |
RR |
18 |
SpO2 |
97% |
BMI |
33 |
The physical exam is essentially unchanged from the previous exam.
You obtain the following labs:
Test | Value |
---|---|
Na | 137 |
K | 3.4 |
Cl | 100 |
HCO3- | 22 |
BUN | 20 |
Cr | 1.3 |
Urinalysis shows no protein.
Per his journal, his blood pressure remains uncontrolled. Review of records shows he is filling his medications as would be expected. You discuss that he will need an additional medication. He expressed disappointment but agrees to start a second agent. You add amlodipine and tell him about the possible side effects.
After six months on chlorthalidone and amlodipine, his blood pressure journal shows moderately better readings but still averages ~150/95.
UA shows trace protein.
You add lisinopril. His follow-up BMP one week later is stable. You up-titrate the medication dose.
Two weeks later, he presents to the emergency room. Below is a representative picture from his physical exam:
Visualdx via Uptodate. Internal use only. Do not reproduce.
He denies having trouble breathing. He is watched overnight in the hospital, and experiences no additional swelling or dyspnea, therefore he is discharged home. Lisinopril is discontinued and added to his medication allergy list.
You see him in the outpatient clinic 1 week later and start him on valsartan, telling him this is a drug that is a “cousin” to lisinopril, but without the same potential side effects. You also initiate a workup for secondary causes of hypertension.
A CXR is obtained:
You order a sleep study. The results return showing Mr. Brown has obstructive sleep apnea, and he is started on nightly CPAP therapy.
You also order an aldosterone:renin ratio which comes back as normal.
You ask Mr. Brown if he has been taking all of his medications as prescribed. He sheepishly reports there is one he hasn’t been able to take since it was prescribed to him, because he can’t afford it. You then prescribe losartan. After this change goes into effect, you are able to get consistent readings of ~ 130/80. You continue to see Mr. Brown in clinic, and do not order any further workup for his hypertension.